CAMHS - Ministerial Response - 31 July 2014

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Comments

1

The majority of parents told the Panel their experience of the CAMHS service was one of  little  positivity  with  an overall  lack  of  holistic support resulting in a feeling of  isolation  throughout  the process (section 1.3).

It is always concerning when anyone using services feel they have not had the support they wish. It is recognised that many parents who are quoted within the report had concerns around managing aggression and behavioural issues within the home. This is an issue that needs to be addressed by comprehensive CAMHS and H&SS Children's Services. It will be essential for partner agencies to work with HSSD in addressing this under the auspices of the children and young  people's  strategic  framework.  (Partner agencies in this context include the Department of Education, Sport and Culture (ESC), the States of Jersey Police (SoJP), the Probation Services as well as voluntary and charitable sector organisations such as  NSPCC  and  Mind  Jersey  for  example).  The department also intends to explore the possibility of developing  a  Behavioural  Support  service  which would  work  with  other  professionals  in  providing support and guidance to parents who are managing children and  young people  who present with very challenging behaviours particularly aggression.

Subsequent  to  the  report  production  some  service users  have  spoken  to  both  team  members  and managers  about  their  positive  experiences  of  the

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service contrary to what they have heard reported. It is therefore important to balance the concerns heard by the panel with the positive experiences of many other services users.

2

Specialist  CAMHS  sits within the 4 tier system and it is important it is viewed as a specialist  service  within  the overall  Comprehensive CAMHS environment and its role is understood.

This is an important principal when considering these recommendations as the responsibility for the mental wellbeing of all our children and young people sits across a range of agencies and the voluntary sector. It is  recognised  that  there  is  a  need  for  specialist CAMHS to both develop new links and strengthen existing  relationships  with  their  comprehensive CAMHS partners. (Partner agencies in this context include  the  Department  of  Education,  Sport  and Culture (ESC), the States of Jersey Police (SoJP), the Probation  Services  as  well  as  voluntary  and charitable sector organisations such as NSPCC and Mind Jersey for example).

The Comprehensive CAMHS agenda is in line with national policy development that identifies the need for comprehensive CAMHS to be delivered via all tiers  of  service to provide  timely, integrated, high quality multidisciplinary health services for children and young people.

3

Jersey CAMHS comes under the  Children's  Service Directorate  which incorporates  all  Children's Services (section 2.2).

Children's  Service  incorporates  Children's  Social Work, residential services and CAMHS. Paediatrics, including community paediatrics sits within hospital services.

4

The Panel believes 18 months without  a  registered  family therapist is unacceptable and is  very  concerned  the importance of family therapy is  being  overlooked (section 3.1).

The  service  recognises  the  importance  of  family therapy  and  the  majority  of  the  clinicians  have training and experience of systemic family therapy but  not  to  Master  level. Unfortunately  recruitment and retention of appropriate professionals has been difficult and therefore a decision was made to train a local professional who is committed to the service and the island. Her training will be fully completed in 2 years. There is also investment in providing some training  for  other  clinicians  to  enable  a  team approach.

5

The Specialist CAMHS team feel  overwhelmed  with  the change in demand on service due to the increase on referral rates  for  urgent  and emergency  assessment  of individuals.  This  increase  in demand requires CAMHS to review  the  services

Increases  in  young  people  self-harming  leading  to greater  urgent  and  emergency  assessments  has become a national concern (WHO, health behaviours in school aged children 2014).

The recognition of the pressures that the CAMHS team is under is welcomed.

H&SS have been a leader within the States in the development  of  the  Jersey  Lean  System  and

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provided (section 3.4).

managers  and  clinicians  are  keen  to  embrace  this model and in conjunction with Tees, Esk and Wear Valleys NHS Foundation Trust, will hold a series of Rapid  Process  Improvement  Workshops  (RPIW) with stakeholders. The organisation is already in the process of preparing for these workshops that will commence in August 2014.

6

The lack of a full  range of care  pathways  needs  to  be addressed  without  delay. Intervention  is  not  taking place  as  frequently  as  it should  at  tiers  1  and  2 resulting in cases being left unsupported (section 3.5).

Children  Services  are  keen  to  work  with  partner agencies to support the development of tier 1 and 2 services as part of comprehensive CAMHS. There is already  a  model  of  good  practice  involving supervision and consultation by specialist CAMHS staff for professionals working in tiers 1 and 2 which can be further developed with the formalisation of care pathways across the tiers. (Tiers 1 and 2 include G.P.s,  teachers,  psychologists  and  counsellors working in schools and primary care for example).

7

The general lack of accurate information and statistics for month  on  month  referrals makes it difficult to gain an understanding of the overall caseload  or  when  a  case should  be  closed (section 3.6).

It is recognised that more detailed and accurate data would  be  of  benefit  to  the  service  in  managing demands. It would however be appropriate to base case  closure  on  statistical  information  and  an assessment of need.

8

The  majority  of  the recommendations  from  the Young Minds Report in 2006 have  not  been  fully implemented (section 4.1).

Documentary  evidence  provided  to  the  Scrutiny Panel  review  showed  that,  of  the  17 recommendations made in the Young Minds Report, 15 had been acted upon following publication of the report. It should be recognised that the Young Minds Report was published in 2006 and there has been significant  change  in  this  area  in  the  following 8 years.  Inevitably,  in  some  areas  the recommendations  are  no  longer  as  appropriate  or have been superseded.

9

The  official  definition  and description  of  CAHMS provided  by the  Health and Social  Services  Department should be the service parents and  users  expect  to  be available (section 4.2).

This is always the aim of CAMHS and should be a basis to monitor provision. The service is looking to develop more effective ways to access service user and  carers  views  which  will  include  agreeing  a meaningful definition and description.

10

Parents  found  it  frustrating that they could not access the excellent  support  service from Autism Jersey without a formal  diagnosis  and  as  a

Diagnosis of Autism Spectrum Disorders (ASD) is carried out by a multi-agency team which includes Paediatricians,  Educational  Psychologists,  Speech and Language Therapists and CAMHS professionals. This cross departmental group is known as the Team

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result,  felt  unsupported  by the Department of Health and Social Services (section 5.2).

for Assessment of Autism and Social Communication (TAASC). In the past parents have accessed Autism Jersey (AJ) when their child had been identified as having social communication difficulties and had not required a diagnosis. If the situation has changed the organisation would wish to work with AJ to see how best  to  support  parents  when  their  child  has significant social communication difficulties but do not have a formal diagnosis.

11

The  Panel  believe  the approach of the YES Project achieves  results  and  is meeting  the  needs  of vulnerable  children  and young  people  who  seek advice (section 5.4).

The Youth Enquiry Service (YES) provides one to one counselling, drop in services for young people as well as on-line advice. It is an important part of tier 2 CAMHS and have links to specialist CAMHS. This provision,  with  school  counselling,  give  young people  wider  choices  as  to  how  to  address  their mental health needs.

12

Mind Jersey offer support to adults  with  mental  health issues  and  their  families however,  no  similar  service for families with children and young  people  is  currently provided (section 5.5).

Meetings are already commencing with Mind Jersey to look at the possibility of extending their support to young people and their parents.

13

The  Panel  is  aware  of  a number  of  local organisations  who  support parents  and  children  with mental  health  issues.  These groups  must  be  included  in any service development by the Department of Health and Social  Services  due  to  the fact  they  have  first-hand experience of the difficulties faced  by  many  families (section 5.5).

H&SS  are  committed  to  working  with  voluntary agencies  and  support  groups  for  children,  young people with mental health issues and their carers in developing services. The department would always encourage any group that feel they do not have an effective voice to contact managers or the Minister to discuss how best to develop links.

14

Due to the lack of necessary systems  in  place  to  collate data,  CAMHS  is  unable  to manage  demand,  capacity and  its  caseload  effectively. In the absence of the relevant data  and  based  on  Royal College  of  Psychiatrists recommendations,  the Panel's  advisor  believed CAMHS  has  capacity  to manage  the  number  of

It is recognised that currently there is no effective IT system  for  collecting  the  data  needed  to  support effective capacity management and that this needs to be considered alongside other mental health services as part of the external mental health review.

The  Royal  College  of  Psychiatrist  published  their report – Building and sustaining specialist CAMHS to improve outcomes for children and young people: Update  of  guidance  on  workforce,  capacity  and functions of CAMHS in the UK in November 2013. This  discusses  the  complexity  of  developing guidance on workforce planning. Currently CAMHS

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referrals being accepted and could  manage  its  caseload and deal with the capacity to meet the increase in referrals with an improved framework of  case  management (section 6.1).

has  13  WTE  clinical  staff.  The  data  on  caseload management assumes that every clinician is working directly with families full time and does not allow for other  roles  such  as  intensive  support  (where  an individual young person may receive the equivalent of  1  member  of  staff's  time  over  the  week) consultation,  supervision,  training,  service development  and  input  into  multi-agency  work. However it is recognised that the service needs to review it caseload management and capacity.

15

The Panel has concerns that following the  initial referral to CAMHS the expectations of  parents,  children  and young people could be raised even  though  there  was  no guarantee they would be seen and  offered  treatment (section 7).

Clear  guidance  is  required  for  professionals  with regard to referral for assessment that may or may not lead  to  treatment  by  the  specialist  CAMHS  team. Consideration of referral processes are essential in developing  the  care  pathways  with  tier 1  and  2 services as previously suggested. Referral pathways will  be  part  of  the  Rapid  Process  Improvement Workshops.

16

Once  a  referral  had  been made  by  a  Professional, CAMHS  request  further information from the patient and  family  resulting  in  the wait for routine appointments being  lengthy  with unnecessary  delays.  The waiting  time  for  an appointment  has  more  than doubled  over  a  year  from 6 weeks  to  14  weeks (section 7).

CAMHS  send  out  standardised  questionnaires  to families when a referral is received in line with the practice  of  many  similar services  in the  UK. The questionnaires enable –

1. Screening  for  risk  which  facilitates  bring appointments  forward  if  significant  risk  is identified.

2. Collecting  clinical  information  in  a  systematic way to inform planning for the assessment.

3. Gathering information of the young person and parents  views,  family  members  and  school attended  to  inform  the  planning  for  the appointment  and  also  indicating  if  further information is needed.

In the vast majority of cases the questionnaires are sent with the appointment and therefore do not effect waiting time.

The increase in waiting time has been due to both the increase in number of referrals and the greater levels of severity and complexity of the referred problems. Effort has been made to manage demand and reduce wait times by introducing a triage team which is now starting  to  have  an  impact.  Due  to  the  changes already made to deal with the demand the waiting time has reduced to 10 weeks for first appointment, with the aim to bring this down further. This is not dissimilar to many services in the UK. It is better than  some  but  not  as  speedy  as  others.  The department  is  committed  to  finding  new  ways  of

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managing referrals.

NHS service in Scotland in January 2014 reduced there waiting time targets from 26 weeks to 18 weeks for access to CAMHS. In England the waiting time target has been 18 weeks since 2010.

17

Currently there is a lack of detailed  information available  on  the  number  of admissions into the service of vulnerable  children  and young people who have self- harmed  or  suffering  from other  behavioural  or  mental health  condition (section 7.1).

Issues  related  to  availability  of  data  have  been addressed previously.

18

It  is  imperative  that  the service  has  a  systemised approach  to  recording activity  so  that  this  can  be closely  monitored,  ensuring quality standards do not slip (section 8.1).

This is agreed as discussed previously.

19

Feedback  on  the effectiveness  of  treatment and  outcomes  are  not currently available due to the infancy  of  the  new  system and  insufficient  data.  The Panel  is  disappointed  this practice  was  not implemented  sooner (section 9).

Obtaining good outcome measures for CAMHS has challenged services across the UK and considerable work  has  been  undertaken  to  agree  recommended data sets. Specialist CAMHS is now collating data in line  with  other  services  in  the  UK  so  that comparative data will be available. It recognised that systems to enable service user feedback and outcome data are also a challenge for several services in the UK.

20

Due  to  the  general  lack  of holistic  support  received from  CAMHS  and  other agencies,  families  are suffering. Siblings have been separated  and  have  had  to live outside the family home and  instead  of  an  overall family  approach  to  caring, the focus tends to be on the individual  rather  than  the family unit (section 10).

It can be a challenge for services and families to try and  meet  the  competing  needs  of  different  family members  and  the  ethos,  based  on  best  practice guidance, is to maintain children within their own homes.

CAMHS always endeavours to works systemically and it is rare that a young person or child would be seen  without  contact,  review  and  advice  to  their carers; however issues related to mental capacity and levels  of  risk  will  influence  delivery  of  care. Frequently  joint  sessions  would  be  offered  to  the young person and their parents.

Families' expectations of services and what is seen as acceptable vary and a challenge to staff is to provide the flexibility of response that is required.

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It is recognised that specialist CAMHS with partners within comprehensive CAMHS need to be clearer as to what they can provide within their agreed remit.

21

The  Panel  has  serious concerns about the time taken to diagnose children who may be  on  the  autistic  spectrum, with  the  waiting  list  from referral  to  diagnosis  of 9 months. The Panel believed the closure of the waiting list due  to  full  capacity  was unacceptable (section 11.1).

The time taken from referral to diagnosis will vary considerably from case to case depending upon the nature of a child's presenting skills and difficulties. A number of steps have been undertaken to improve the length of time between acceptance of a referral and feedback  to  parents  on  the  outcome  of  the  multi- disciplinary  diagnostic  assessment.  As  part  of P.82/2012  investment,  co-ordination  of  TAASC assessment  has  been  moved  under  the  Child Development  Centre  with  increased  administrative support  for  the  team.  Work  is  currently  being undertaken  to  streamline  the  assessment  and feedback process and improve  communication and support to families during the diagnostic assessment process.  From  June  2014,  all  families  have  been given access to the Family Care Co-ordinator based at the Child Development Centre for information and support around the diagnostic process.

Since December 2013, all referrals accepted by the team are allocated a target date for feedback to the family  on  diagnostic  assessment.  For  referrals accepted  in  2014  the  average  time  between acceptance of referral to target feedback date is an average  of  5.29 months  with  a  range  of  range

2.3 months to 8.8 months.

22

The  Panel  is  extremely disappointed  that  mental illness is not held in the same regard  as  physical  illness. Diagnosis  of  mental  health still proves to be difficult and pathways  are  unclear. Without a diagnosis, support is not offered and the needs of undiagnosed children and vulnerable young people are not met (section 11.3).

A recent UK policy document "No Health without Mental Health"  highlights that mental health must have  equal  priority  to  physical  health.  This  is  an ongoing challenge for mental health services across the life span. H&SS through P.82/2012 are enhancing a wide range of services to ensure that mental health issues  are  given  equal  priority  with  physical conditions.

Children presenting to mental health services do not necessarily have a formal mental health condition but may  still  need  support.  Often  when  there  is  an emerging mental health condition the diagnosis may not initially be clear and may take time to become more  apparent.  Specialist  CAMHS  endeavours  to provide services based on need rather than diagnosis. When there is a formal diagnosis the service will use best practice guidance to inform interventions (e.g. NICE guidance).

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23

Stigma is an important issue that  must  be  addressed, otherwise children and young people are less likely to seek support  for  their  mental health needs (section 13).

The emphasis on removing stigma is welcomed and the  ongoing  work  between  mental  health  services, public health, education, Mind Jersey and Samaritans to address this needs to remain a priority.

24

Although  P.82/2012  is  a 10 year  plan,  the  specific area  of  children  and  young people's  mental health does not seem to be a priority. As a result little will be done to address and bring to the fore increasing  mental  health issues in children and young people (section 13).

Phase  1  of  P.82/2012  created  a  range  of  service enhancements  for  children,  and  Phase  2  addresses children's mental health as a priority. The additional investment into the child health system in Phase 1 remains  relevant  to  mental  health  as  the  research evidence shows that the priorities for investment are likely to have positive impact on children's mental health.

Early  Interventions  improve  a  child's  social  and emotional  capability.  Health  economists  have calculated that a return of up to 3 to 7 times the original investment could be achievable by the time the young person is 21 years of age.

Phase 1 included mellow parenting, family care co- ordinator, Samares children centre, Sustained Home Visiting  and  increased  access  to  primary  care  for under 5s which are all part of a tiered comprehensive CAMHS model.

Phase 2 of P.82/2012 identifies further investment for mental  health  services  in  2016-2019  that  will  be informed  by  the  completed  mental  health  service review. CAMHS is an important part of the mental health service review and as such will be the focus for future service redesign and service improvement.

25

It is difficult to determine at present  whether  additional resource  would  find  a solution  to  the  existing problem  of  workload (section 15.1).

The  Royal  College  of  Psychiatrist  published  their report – Building and sustaining specialist CAMHS to improve outcomes for children and young people: Update  of  guidance  on  workforce,  capacity  and functions of CAMHS in the UK in November 2013. This  discusses  the  complexity  of  developing guidance on workforce planning. Currently CAMHS has  13  WTE  clinical  staff.  The  data  on  caseload management assumes that every clinician is working directly with families full time and does not allow for other  roles  such  as  intensive  support  (where  an individual young person may receive the equivalent of  1  member  of  staff's  time  over  the  week) consultation,  supervision,  training,  service development  and  input  into  multi-agency  work. However it is recognised that the service needs to review it caseload management and capacity.

This is an important question which will be addressed

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both  by  the  more  immediate  Rapid  Process Improvement Workshops and the full mental health review. These will look at the service's capacity in relation to Jersey's need and what, if any, further resources  are  required.  In  the  meantime  some additional resources have been provided to help to bring down the waiting time and meet the increasing demands.

26

In the absence of alternative accommodation  the paediatric  ward  within  the general  hospital  is  used  to receive  children  and  young people with a wide range of mental  health  problems (section 16).

It is recognised that this is not ideal however on a small island it is not possible to have a specialised unit. Other islands and areas in the UK also use the paediatric  wards  for  similar  needs  and  this  is currently been reviewed.

The  majority  of  children  and  young  people  are admitted after episodes of self harm and both NICE and  College  of  Psychiatrist  guidance  recommends that they are admitted under the care of the paediatric service over night for review by CAMHS clinicians the following day.

The plans to provide an adolescent area on Robin ward  have  been  brought  forward  to  commence  in 2015 in order to provide a more appropriate and safer environment.

27

Parents  spoke  positively about the work of the States of  Jersey  Police  in  helping parents  to  deal  with potentially  very  difficult situations  within  the  home environment,  especially outside  of  normal  working hours (section 17.2).

H&SS  has  a  good  working  relationship  with  the States  of  Jersey  Police  and  recognises  the  very important  contribution  they  make  to  supporting families in crisis and managing risk to young people.

When  a  young  person  is  aggressive  and  their behaviour  cannot  be  contained  by  their  carers  the police are the only agency that has statutory powers to intervene and this is often an important first step in managing the situation before other services are able to intervene. These partnership arrangements will be further considered within the mental health review.

28

A subgroup has been formed to  specifically  look  at accommodation  for  all individuals who have mental health  problems  and  it  was hoped  the  sub-group  would report on their findings later in the year (section 17.3).

The  Head  of  Crime  Services  is  leading  a  group looking  at  Places  of  Safety.  Plans  to  refurbish existing  facilities  to  meet  this  need  have  been completed and a broader review of the mental health estate in the context of the new Hospital development is underway.

29

There is no clear designated place  of  safety  for  young people  in  Jersey  and  little clarity  around  what  a designated  place  of  safety

Keeping children and young people safe is initially the  responsibility  of  their  carers,  when  the  risk become too great a partnership is needed between carers and professionals from a range of agencies to develop a plan to minimise the risks to the young

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should be. Although Orchard House is an adult facility, it has been used in the past to house  vulnerable  youngsters under  the  age  of  18 (section 17.4).

people.  Their  needs  can  be  very  different  and therefore staff and accommodation resources have to be used flexibly to meet these needs.

The mental health review will be considering how best  to  meet  the  needs  and  minimise  risks  for individual  with  acute  mental  health  difficulties including young people.

30

The  Education  Department has  a  major  part  to  play within  Comprehensive CAMHS and it is important the  relationship  between Education  and  Specialist CAMHS  is  strengthened (section 18).

The  Education  department  is  a  key  stakeholder within Comprehensive CAMHS and is aware of the importance of strengthening existing links.

CAMHS  clinicians  deliver  the  required  clinical supervision  for  all  school  counsellors  and  regular consultation is offered to MAST professionals.

CAMHS  continue  to  work  collaboratively  with Education in the development of policy and guidance and  joined  up  care  pathways  about  how  schools should respond to self-harm or risk issues amongst pupils.

31

Although  the  establishment of  a  multi-agency safeguarding  hub  was extremely positive, the length of  time  it  has  taken  to establish  was  disappointing as it was a recommendation from the 2006 Young Minds Report (section 19).

This  is  incorrect.  MASH  are  a  relatively  new development across the UK. The first MASH was trialled in Devon in 2010. Many UK local authorities are yet to develop their MASH services.

32

The  responsibility  of  early intervention does not just lie with Specialist CAMHS and all  stakeholders  need  to understand  their  role (section 20.1).

This  finding  is  welcomed  and  fundamental  to  the development  of  a  sound  comprehensive  CAMHS model.  The  Minister  and  managers  within  H&SS look forward to working with colleagues from other departments in moving this forward.

33

There is a gap in provision for  emerging  mental  health problems  and  the  point  at which  Children  and  Young People  attend  at  CAMHS with  acute  mental  health problems. Early intervention and  prevention  are  key  to more  positive  outcomes  for children,  young  people  and families (section 20.1).

H&SS recognises the need for all partners to work together to further develop comprehensive CAMHS and support the development of tier 1 and 2 services with a clear documented care pathway. This is further highlighted  in  other  responses.  The  mental  health review will help to identity appropriate models which are  likely  to  include  IAPT  (Improving  Access  to Psychological  Therapies)  for  children  and  young people.

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34

The  Panel  has  concern  that there  could  be  vulnerable young  people  from  ethnic minorities who are not able to gain immediate access to the  service  due  to communication  difficulties (section 21).

The service recognises this is an area that should be further addressed both through the service redesign and mental health review.

35

Once a child or young person is under the administration of CAMHS  and  receiving medication,  only  CAMHS professionals  can  prescribe that medication. Information received  by  the  Panel  from witnesses seemed to indicate that medication seemed to be the first choice of treatment (section 22.1).

Best practice guidance for a range of mental health conditions  recognises  the  need  for  medication  but always in the context of other support and therapy.

36

Most parents did not believe their  child  was  being  re- assessed  on  a  regular  basis and  as  a  consequence remained  on  the  CAMHS register with no pathway or solid  plans  for  future development (section 24).

Many  children  and  young  people  receive  brief interventions set out in an agreed plan. The service recognises that fuller written documentation would be helpful for service users and colleagues and this will be addressed in the service redesign. The service also  wishes  to  work  with  service  users  to  better understand  how  best to  communicate  and  monitor treatment plans for those that are in the service for more  prolonged  periods  with  greater  clarity  with regard to the frequency of review.

37

All  stakeholders  raised concerns over the lack of an appropriate  out  of  hour's service.  As  the  Children's Service  has  overall responsibility  of  CAMHS and the treatment for mental health issues, the Panel was very  disappointed  that  a suitable out of hour's service was  not  being  provided (section 25).

The department has an agreed pathway for out of hours  provision  agreed  by  both  Hospital Paediatricians and States of Jersey Police.

It is acknowledged that an on call service provided by specialised CAMHS would be ideal, however it was  recognised  by  Young  Minds  that  this  is  not feasible within a small community.

The Royal College of psychiatrists and other bodies also state that in smaller services CAMHS on call is not viable and endorses the type of arrangements in place in Jersey.

38

Concern was raised that there was no clear guidance from CAMHS  about  what information could be shared with  families  resulting  in parents feeling uninvolved in their child's care. The Panel

Confidentiality is discussed at the first appointment with  young  people  and  their  carers.  When  any CAMHS  professional  has  concerns  about confidentiality  or  consent  this  is  discussed  with senior clinicians.

Most young people are happy to have their parents

Findings

Comments

has concerns that not enough attention is given to how the situation affects the family as a whole (section 26).

involved in their treatment and even those who are initially  reluctant  will  often  agree  following discussion and support to sharing of information.

This is recognised within the UK as a difficult area as young people mature, develop greater independence and autonomy over a period of time while also still cared for by their parents.

The  introduction  of  a  Mental  Capacity  Law  will provide greater clarity although the tension will still remain.

Provision of written information about capacity in relation  to  confidentiality  and  consent  for  under 18 year olds will be developed within H&SS.

39

Currently the Island does not have  a  Mental  Health Capacity  Law  to  address matters of confidentiality for those suffering from a mental health  condition (section 26.1).

A Mental Capacity Law is currently a priority for the department and work is ongoing with the law officers department  to  facilitate  this.  In  the  meantime  the organisation has ratified a mental capacity policy and training is being rolled out to support this.

There  are  some  discrepancies  between  UK  best practice and the current legal situation in Jersey for under 18 year olds  and  practice  guidance  is  being drawn up for practitioners.

40

In  general,  transitions between  child  and  adult services  could  be  better managed. Although the Panel recognises  the  need  for continuity,  there  must  be  a more  seamless  practice  in place  to  allow  vulnerable young  people  to  make  the transition  into  adult  mental health services (section 27).

Over recent years there have been increased numbers of  young  people  moving  from  CAMHS  to  adult services  including  those  with  developmental disorders.  A  transition  pathway  is  currently  under development  with  Adult  Services  and  the  Mental Health  review  will  consider  the  interface  between services  and  how  to  improve  the  service  user experience and minimise any anxiety or distress at these difficult times.

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

The Minister for Health and Social Services should ensure the following –

1

1.1  Articulating a vision

Accept

As  a  first  step  a  Lean approach will be taken to redesign  the  current service  in  line  with  the increased  demands. Agreement  of  a  vision with stakeholders will be a priority within a series of  Rapid  Process Improvement Workshops  (RPIW) commencing  in  August 2014.  This  will  be further  developed  with stakeholders  as  part  of the mental health review.

1st Facilitated workshop completed w/c

18th August 2014

CAMHS  staff  needs  time  to develop their vision and strategy going  forward,  this  needs  to reflect  changing  demand  and changing  workforce.  The  team would  benefit  from  a  facilitated team building day to develop and gain  clarity  on  their  vision (section 3.3).

2

1.2  Strategic planning to reflect

Accept

To  be  addressed  within the  RPIW  and  Mental health review.

12 months

Increased demand requires a shift in  provision  by  CAMHS. CAMHS needs to be sure of its role within children's services not just those provided by health and social  care  but  with  wider interdependent  partners,  for example  acute  care  colleagues, education  colleagues (section 6.1).

3

1.3  Development  of  protocols

Accept

To  be  addressed  within the  RPIW  and  Mental health review.

18 months

The  children's  directorate includes  social  care  and  health. There is an advantage within the structure  to  develop  clear pathways  and  joint  working opportunities to address the needs of  children,  young  people  and

Recommendations

To

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Comments

Target date of action/ completion

their  families  who  may  need provision  from  both  sets  of services.  This  can  be  led  by Senior  Management  who  have oversight  of  several  services which  naturally  work  together (section 2).

4

1.4  Defining  and  developing

Accept

Pathways are already in development  and  this process will continue in conjunction with partner agencies.

18 months

The  development  of  streamlined care pathways for eating disorders, neurodevelopmental disorders and transition to adult services would benefit  the  team,  fellow professionals  and  those  who  use the service. There would also be the  advantage  of  applying  joint working  opportunities  to  these pathways (section 3.4).

5

1.5  Develop  CAMHS

Accept

This  recommendation is fully accepted but a more realistic  6  month  time scale will be actioned to allow  for  the development  of  a communication  strategy in  line  with  the  initial planned work to redesign the service.

6 months

communication  and  marketing

CAMHS has a website containing information  about  its  provision, this should be regularly updated, ensuring  that  it  is  widely publicised. CAMHS management should  link  with  the  Directorate communications office to develop a  marketing  strategy  and communication  plan  to  ensure understanding of stakeholders and families  around  the  CAMHS vision  and  offer.  An  emphasis should  be  placed  on  marketing Specialist  CAMHS  business  so that  stakeholders  and  families understand the service  and don't develop  expectations  which cannot,  and  should  not,  be delivered  by  a  specialist  CAMH service (section 3.3).

6

1.6  Strengthen  leadership  for

Accept

A  new  management structure  is  being developed  for  CAMHS

3 months

CAMHS,  clarity  about  role  and

direction of travel for service

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

CAMHS  would  benefit  from  a management  team  who  are experienced  in  change management  and  strategic working  to  drive  forward  future plans for the service and embed within  the  children's  directorate. There  should  be  a  developed philosophy  of  being  outward facing to halt the perception that Jersey  CAMHS  is  isolated  and works  in  a  silo  as  was  often reported by witnesses. This needs to  be  modelled  by  management. CAMHS  management  should have  sufficient  knowledge  and understanding  with  the  authority to be able to support effective and efficient multi-agency delivery of CAMHS (section 3.5).

enhancing their ability to carry  through  the changes  and  strengthen their position within the organisation  whilst maintaining the delivery of the service.

Senior  managers  within H&SS will be supporting CAMHS professionals in developing  the  service and  provide  additional skills in change and risk management.

7

1.7  Professional mix

Accept

The  initial  statement  of staff  mix  will  be identified  within  6 months and implemented within 18 months. To be addressed  within  the RPIW and Mental health review.

18 months

The  team  need  to  ensure professional  mix  and  provide  a service which accounts for skills, competencies  and  capabilities  of its team members.

8

1.8  Refresh  supervision

Accept

Supervision is central to the work of the team and encompasses  clinical, case  load  management and  managerial supervision.  The  exact nature of this is informed by  the  requirements  of the different professional bodies.  All  team members  also  have annual  appraisals  which will look at training and development needs.

Demand  and  capacity will be reviewed as part of the RPIW.

6 months

framework  to  ensure  that  any

Ensure  that  a  supervision framework  is  established  which includes  managerial  supervision, caseload  management  and recognition of training needs. The framework  needs  to  ensure  that cases  are  being  managed adequately and staff are receiving appropriate support and guidance. The team's case load is excessive which  indicates  lack  of management  of  demand  and capacity.  Difficulties  in recruitment to an island need to be

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

observed.  Ensuring  skill  mix management  will  support  staff being  developed  to  provide appropriate  interventions  which respond  to  needs  of  children accessing service (section 6.1).

9

1.9  Refresh  Operational  Policy

Accept

The  operational  policy will  be  updated  in  line with the redesign of the service.

6 months

for CAMHS to ensure its fit for

With  change  in  demand  and provision, the operational strategy should reflect this.

10

2.1  Demand  and  capacity

Accept

The  most  appropriate model to meet the needs of  the  island  will  be explored  through  the planned  modelling exercises. Jersey size and geographical  isolation provides  some challenges  to  these models due to the lack of Tier  4  intensive  and specialist services so that through  put  is significantly impacted on by meeting the needs of children  and  young people  who  require intensive support.

12 months

management  model  to  be

The introduction of a capacity and flow  model  such  as  Choice  and Partnership  Approach  (CAPA) will allow for a more systemised approach  to  managing  demand and skill mix (CAPA is explained in more detail later in this report under  the  chapter  "Models relevant to CAMHS"). The team will have to invest time in training for  this  and  introducing  this model as a  systemised approach to manage demand. This approach was  independently  evaluated  in 2009 and the benefits have been clearly recognised (section 28.1).

11

2.2  Training  programme  for

Accept

A training plan is already in  place  which  includes Family  Therapy  and Cognitive  Analytical Therapy  training  for several  team  members, whole  team  training  in Dialectic  Behavioural Therapy  and  continued updating  in  child protection  and  risk assessments.

Thought is already been given  to  the  training

18 months

workforce which is  reflective  of

As recruitment of individuals with specialised  skills  is  a  challenge, the team will need to ensure that they  have  an  up-to-date  skills analysis  to  identify  deficits  and plan how to address these. CAPA can  also  assist  with  this (section 28.1).

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

needs  for  next  year which  will  be  informed by the future reviews.

12

2.3  Affiliation  to  a  national

Accept

CAMHS have used this resource to inform their outcome  measures  to ensure  they  can  be compared  with  the  UK. Once a more robust data management  system  is developed CAMHS will be  in  a  position  to affiliate to CORC.

6 months

body such as CAMHS Outcomes

Research Consortium (CORC)

CORC  provide  a  suite  of measures  and  will  assist  with training and implementation

The team can benchmark, receive training for staff and ensure that an  outcomes approach  is central to service provision (section 29).

13

2.4  Quality  management  and

Accept

The  governance framework  will  be further  developed through  the  RPIW  and Mental health review.

CAMHS  clinicians  are involved in regular audit meetings  with  their peers.

The organisation is in the process of ensuring that risk registers are in place across  all  services including CAMHS.

There  is  an  open approach  to  reviewing case  management  in order  to  improve practice.

Team  members  have readily  engaged  in learning  opportunities through  internal  and external  reviews  post incidents.

One  of  the  senior clinicians is a member of the Safeguarding board.

6 months

Governance  and  accountability needs  to  be  refreshed  by  the development  of  a  quality framework  which  could  include audit  activity.  Quality  standards will need to be identified which fit to wider corporate objectives and NICE guidelines.

The introduction of a risk register will also be helpful for the team to ensure  safe  services.  The  team should  keep  a  risk  log  which keeps  a  record  of  identified governance and quality risks, how they will be mitigated and when they need to be escalated. Quality frameworks  can  also  include management  of  learning  post incident or complaint as well as how  the  team  benchmarks  itself against  the  Directorate  quality standards.

Establishing  a  clear  relationship with the Safeguarding Board can be  built  into  the  framework,  to strengthen accountability and the governance  framework  together with development of information sharing  protocols  which  link together  various  services  with

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

defined  working  together agreements  and  pathways including  a  communications strategy (section 8).

14

2.5  Referral pathway

Accept

This  will  be  addressed with the RPIW.

6 months

Clarity around referral criteria is imperative  to  safe  working practice. CAMHS should develop its inclusion and exclusion criteria based  on  the  existence  of definable  mental  disorders  and impact  of  family  and  social functions.  Process  mapping  the referral  process  to  ensure efficiency  and  clarity  and refreshing referral paperwork and consideration  of  making  this accessible online (section 3.5).

15

2.6  Develop  evidence  about

Accept

To  be  addressed immediately  within  the RPIW  with  more detailed  development  as part of the Mental health review.

6 months

team's performance

Collating  data  which  reflects performance  is  imperative  to understand  activity  versus demand  and  to  influence  any future  investment.  Senior Management  may  also  like  to consider  putting  in  place  some performance targets, for example an  acceptable  waiting  time  for first appointment and a reporting mechanism (section 3.6).

16

2.7  Ensure  all  staff  understand

Accept

Currently  confidentiality is  discussed  at  the  first appointment  with  a young  person  and  their family and in future, will be provided as a written document.  All  staff  are au  fait  with  Fraser guidelines  and  issues about confidentiality are regularly  discussed  by the team and with other professionals.

 3 months

and  communicate  the  scope  of

confidentiality  agreements  with

children, young people and their

Confidentiality agreements are in place in each child, young person and  their  families  clinical  file. Staff  are  au  fait  with  Fraser guidelines (section 26.1).

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

17

2.8  Statutory  versus  private

Accept

Very  little  private  work is  carried  out  by CAMHS  professionals. Staff  will  however  be reminded  of organisational  policy which will be monitored.

3 months

All  staff  should  be  aware  of conflict of interest around private practice  and  adhere  to  any guidelines  from  the  Directorate around this. It was evident from information gleaned from witness interviews  that  at  times  this practice  had  become  a  point  of confusion for service users.

18

2.9  Development  of  a  detailed

Accept

The action plan will be informed and developed through the RPIW.

4 months

An  action  plan  around  future developments for CAMHS should be  formulated  and  agreed  and signed  off  by  the  Director  of Children's  Services.  Regular reviews and reports of its progress need to be in place.

19

3.1  Identify  early  intervention

Accept

This work was started by the  Children  and  young people's  strategic framework  (C&YPSF) and will be discussed by the  Child  Policy  Group with  agreed  actions being  taken  forward  in the  CYPSF  led  by  the Chief  Minister's Department.

3 months

and early help for children, young

people and their families

Map the  resources  across Jersey who contribute to children, young people  and  their  families emotional health and wellbeing to understand  the  pathways  and resources  currently  available (section 20.1).

20

3.2  Refresh  the  working

Accept

There are currently good working  relationships between  the  2  services with  regular  meetings between senior clinicians however  this  could  be further  formalised  with agreed protocols.

Work  is  underway  to develop  a  Jersey Common  Assessment Framework with partners from  the  Safeguarding

6 months

arrangements  between  Education

Psychology  and  Specialist

Explore  the  potential  for teamwork  around  the  child arrangements  and  the implementation  of  the  common assessment  framework,  defining the role Specialist CAMHS would play into this. This would create great  opportunities  for  joint working  arrangements.  There should  be  an  emphasis  on

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

working across agency boundaries and  within  a  variety  of  settings (section 18).

Board

21

3.3  Supporting  schools  and

Accept

To  be  addressed  with key partners such as ESC and G.P's in the RPIW, the Mental health review and  the  Primary  Care Review.

12 months

Explore  the  potential  for providing  specialist  support  to primary  care  and  education through a consultation model. A referral screening approach could also  be  implemented  situated  in community  settings.  Training packages can be developed with Educational  Psychologists  for teaching  staff  in  the  recognition and management of mild mental health problems (section 18).

22

3.4  Ensuring  accessibility  and

Accept

To  be  addressed  within the  RIE  and  Mental health review.

6 months

provision  for  individuals  who

have additional needs

For example those with a physical or learning disability, new comers to Jersey and those from Black, Asian  and  Minority  Ethnic backgrounds.  Provision  of information  which  promotes accessibility for all (section 21).

23

3.5  Development  of  self-harm

Accept

The  Prevention  of Suicide  Strategy  is currently  been  updated with  young  people's issues  seen  as  a  key priority.

As  a  first step  a  multi- agency  working  group has  been  set  up  to address  the  issue  of providing  support  to young  people,  parents and  families  in preventing and managing emotional  and  mental crises.  The  group  have been  charged  with working  together  to

12 months

and risk of suicide guidelines

A  multi-agency  protocol  should be  implemented  to  assist  those who  work  with,  or  support, children and young people in how to recognise risk of self-harm or suicidality  and  which  outlines  a subsequent  course  of  action (section 19).

Recommendations

To

Accept/ Reject

Comments

Target date of action/ completion

identify some short term and  near  immediate actions that will address key  issues  of  concern. There will be a focus on developing key messages and  information  in recognising  emerging distress  and  crises  in order that young people, parents,  families  and support workers can act early  to  prevent  further and escalating distress. A summary of all available services  and opportunities  provided across  departments  and agencies that can support young  people's emotional  and  mental health will be compiled.